BP control ‘remains worse’ in Black, African American adults, even if guidelines followed
Hypertension control was elusive in many Black or African American populations, even when health care providers followed race-based guidelines for the condition, a study showed.
Some of the therapeutic agents included in the study — angiotensin-converting enzyme inhibitors and angiotensin receptor blockers — are established methods of controlling BP and staving off the advancement of kidney disease, Michael Potter, MD, a study co-author and a professor in the department of family and community medicine at the University of California at San Francisco, told Healio.
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Several society recommendations, including the 2017 American College of Cardiology/American Heart Association guidelines, stated that Black or African American people should only be prescribed angiotensin-converting enzyme inhibitors and angiotensin receptor blockers as first-line hypertension therapy when “certain comorbidities” are present, according to the researchers. Conversely, patients who are not Black or African American do not have this restriction on being prescribed those medications.
According to the researchers, the recommendation stemmed from a previous trial that found Black or African American patients experienced a significant benefit from taking calcium channel blockers or thiazide medications compared with angiotensin-converting enzyme inhibitors.
“However, this finding has been challenged, as the treatment regimen for patients on angiotensin-converting enzyme inhibitors included a beta-blocker, which is no longer considered an appropriate regimen for any patient with hypertension and no other comorbidities,” the researchers wrote in the Journal of the American Board of Family Medicine.
Given the benefits of angiotensin-converting enzyme inhibitors and angiotensin receptor blockers, physicians who do not prescribe these medications in Black or African American patients “could unwittingly be contributing to worse outcomes for chronic kidney disease,” Potter said.
The researchers conducted a retrospective, observational cohort study to compare prescribing patterns and hypertension control in Black or African American patients vs. patients who were not Black or African American.
They analyzed 2 years of electronic health record data from 10,875 patients at 31 primary care clinics in the San Francisco area. The mean age of the patients was 56.2 years, 57.8% were women, 94% were covered by health insurance and 18.3% were current smokers. Among the entire cohort, 20.6% were identified as Black or African American. A significantly higher proportion of those who were identified as Black or African American smoked (38.7% vs. 13%) and had a BMI of 30 kg/m2 or higher (52.2% vs. 34.9%) compared with those who were not Black or African American.
The researchers reported that 67.1% of all patients in the study were prescribed one medication for their hypertension and 32.9% were prescribed two medications. Among the Black or African American patients, 61.8% were prescribed one therapeutic agent for their hypertension while 38.2% were prescribed two agents. In comparison, 68.4% of those who were not Black or African American were prescribed one agent and 31.6% were prescribed two agents.
Overall, 46.4% of the Black or African American patients had uncontrolled hypertension (140 mm Hg/90 mm Hg or higher) compared with 39% of those who were not Black or African American.
Of those who were Black or African American and received one medication, 41.3% were prescribed thiazide diuretics, 40.1% were prescribed calcium channel blockers and 18.6% were prescribed angiotensin-converting enzyme inhibitors/angiotensin receptor blockers. These percentages were 27.7%, 30.1% and 42.3%, respectively, in the non-Black or African American patients. In addition, among those prescribed one therapeutic agent, 45.2% of Black or African American patients had uncontrolled hypertension, compared with 38% of patients who were not Black or African American (P < .001). Among those who received two therapeutic agents, 48.2% of patients who were Black or African American had uncontrolled hypertension vs. 41.1% of those who were not Black or African American (P < .001).
According to the researchers, limitations to the study included the inherent underestimations of race and ethnicity on EHRs, the potential that patients’ medication lists were incorrect and the researchers not knowing how patients’ BP was obtained.
“Providers seem to be following race-based guidelines for hypertension, yet hypertension control for Black or African Americans remains worse than non-Black or African Americans,” they wrote.
In the interview, Potter noted that “observational data showed that regardless of which drugs were selected, Black people on average did about as well as everyone else, and there seems to be no justification for avoiding angiotensin-converting enzyme inhibitors or angiotensin receptor blockers to treat hypertension in Black people.”
Potter said that the 2017 American College of Cardiology/American Heart Association guideline section on hypertension has not been updated, and newer guidance from WHO and the International Society of Hypertension “explicitly recommend” different drug regimens based on race.
“Based on our observational evidence, the guideline organizations should be challenged to re‐examine the assumptions behind their recommendations,” Potter said. “They should also make more effort to examine how the recommendations they have been making for generations may unintentionally be contributing to health inequities.”
Perspective
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The authors’ statement that “an individualized approach to hypertension therapy for all patients may be more important than race-based guidelines” is a fair statement. Ultimately, individualizing or personalizing treatment choices in hypertension is an important approach that should be encouraged.
That being said, there are reliable data demonstrating that in general Black or African American patients tend to have a less robust BP lowering response to blockers of the renin-angiotensin system (angiotensin-converting enzyme inhibitors and angiotensin receptor blockers) when they are used in the absence of a thiazide diuretic. Given low and worsening rates of hypertension control in the United States among all ages, sexes and races, we should be focused on using the most effective medications to lower BP. In the absence of well-validated and widely available tools to help “individualize” BP medication treatment choices, busy primary care providers (who treat the vast majority of patients with hypertension in the United States) will default to guideline recommendations.
Limitations such as the ones in this study are inherent in any retrospective observational cohort research and do not have a major impact on the study’s findings.
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